Primecuts – This Week In The Journals

January 24, 2011

By Jeff Shyu, MD

Faculty Peer Reviewed

This past week saw the passage of the Health Care Repeal Act by the now Republican led House of Representatives. This symbolic gesture has little chance of surviving the Senate but almost certainly represents the opening salvo in what will likely be two more years of horse-trading over the legislation, leading up to the 2012 presidential election. One would hope that this next round of debate will contain less vitriol in light of the recent events in Tuscon, but given that the writers of the repeal act elected to preserve the “job killing” part in the bill’s title, I fear the newfound effort towards political civility will be a short-lived one.

Now, rounding up the journals. The current edition of The New England Journal of Medicine (NEJM) features several op/ed articles that address one of the more challenging goals of the Affordable Care Act – how to provide adequate medical services to 32 million newly insured Americans. One, titled “Broadening the Scope of Nursing Practice”, argues for expanding and standardizing the nurse practitioner’s (NP) role in primary care.[1] Despite several studies showing no measurable difference in the quality of primary care services provided by NPs and MDs, a number of medical trade organizations, including the American Medical Association, continue to support direct supervision of NPs by MDs. Furthermore, the roles and responsibilities of NPs vary widely between states – some require physician approval for writing prescriptions, home health care visits, or admitting patients to the hospital, while in other states NPs have far more autonomy. A second article, “Nurses for the Future”, highlights the fact that due to budget constraints and lack of suitable instructors, the number of new NPs has remained flat at 8000 per year despite increased demand, and tens of thousands of applicants are turned away for these reasons.[2] The editorials argue for expanding and simplifying the training of nurse practitioners and changing state regulations on the scope of practice for nurse practitioners as necessary steps to cover the shortage in primary care providers.

The NEJM also featured a research article that sought to better understand why atherosclerotic plaques leading to acute coronary syndromes (ACS) often take place in areas of angiographically mild stenosis.[3] A prospective study was conducted of patients who underwent percutaneous coronary angiography and intravascular radiofrequency ultrasonographic imaging after an ACS, and who were later followed up for other cardiovascular events (death from cardiac cause, cardiac arrest, MI, or re-hospitalization for unstable or progressive angina). The study found that in roughly half of these subjects, events were related to previously non-treated and often angiographically mild lesions. Using ultrasound, researchers were able to determine several predictive features for further adverse events, including a large plaque burden (> 70%, p < 0.001), a small luminal area (p < 0.001), and the presence of a thin-cap fibroatheroma (p < 0.001). The presence of these characteristics may help clinicians to risk-stratify patients who have had an acute coronary event for possible future events.

The latest issue of the Journal of the American Medical Association (JAMA) featured several articles on the ongoing search for diagnostic and predictive biomarkers for Alzheimer’s dementia (AD). One study used florbetapir-PET imaging, which targeted beta amyloid deposits in subjects’ brains and compared them to pathological diagnoses at autopsy.[4] The study group included 35 patients near the end of their lives (29 in the primary analysis) compared to 74 young controls. Of the 29 patients analyzed, 45% had clinically diagnosed AD. 52% had pathologically-diagnosed AD post-mortem. Forbetapir-PET correlated with these post-mortem diagnoses in 96% of cases. The technique was given conditional endorsement by the FDA, which asked the makers of the technique to conduct a further study determining whether the PET images could be reliably interpreted among different readers. Further study may also be warranted to see if florbetapir-PET could be useful in cases of people with mild cognitive decline, or in cases in which the diagnosis of AD is more ambiguous. A study by Kristine Yaffe et al. found that low levels of plasma beta-amyloid were correlated with greater cognitive decline in elderly people without dementia.[5] They saw a greater association in people who had less cognitive reserve (a vague concept, but measured by the authors as self-reported educational attainment and by quantitative scores for literacy). These tests have the potential to help guide and predict the diagnosis of AD in cases where it may be clinically ambiguous.

Also in JAMA, Ellen Freeman et al. studied the use of escitalopram in reducing the symptoms of hot flashes.[6] They conducted a multicenter, double-blinded, placebo controlled trial that showed that the use of escitalopram reduced daily hot flashes by 1.41 episodes per day after 8 weeks (p < 0.001). Hot flashes were also noted to be less severe in intensity in the escitalopram group. Before the study, subjects had 9.78 daily hot flashes at baseline, which was reduced by 4.6 in the escitalopram group and 3.2 in the placebo group. The effect of escitalopram appeared modest especially given a large placebo effect, which has varied from 27% to 52% in other studies. Nevertheless, the drug may be of benefit to people given that hormone-based therapies are no longer routinely used.

And in Lancet, a group of researchers studied the use of an impedance device that increased negative intrathoracic pressure in out-of-hospital patients receiving CPR, and compared this to standard CPR.[7] The theory is that increasing negative intrathoracic pressure during the decompression phase can increase cardiac and cerebral perfusion, leading to improved survival outcome. This impedance device is added to an advanced airway device or facemask and lowers intrathoracic pressure by impeding passive inspiratory gas exchange. The authors enrolled 2470 patients, and found that 9% of the study group survived compared to 6% in the control (p = 0.019), and that the survivors in both groups demonstrated long-term equivalence in cognitive skills, disability ratings, and emotional-psychological status. The major adverse rates were the same, although more patients had pulmonary edema in the intervention group compared to controls (94 compared to 62, p = 0.015). The improvement in overall mortality, although modest on an absolute scale, represents a 50% increase in survival without significant long-term adverse effects. If I needed CPR, I think I would take the device, thank you.

On a final note, with the budget deficit likely to remain front and center in this country’s political debates, it should be noted that many of these studies could not have been possible without the generous funding of the National Institutes of Health (NIH) and other federal agencies, funding that not only advances science and medicine but also provides employment for many people in the United States. I do not envy the difficult budget decisions facing this country, but I also fear that the quality of articles featured by future editions of Primecuts may greatly suffer if support for the NIH is drastically cut.

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